Michael Mithoefer: The Non-Directive Approach Takes Actual Work

Dr. Signi Goldman 19:03

Yeah, is it you that coin? Wait, W, A, I T, why am I talking? Dick Schwartz

Michael Mithoefer 19:07

did that. That was Dick Schwartz.

Dr. Signi Goldman 19:09

Okay, I couldn’t remember, but that’s a good example of that. Okay, keep going. So there’s needed, yeah?

Michael Mithoefer 19:14

Why am I talking so, yeah, a is needed. Don’t say it because you think you need to feel sound smart or useful, or you’re getting bored or something or or you’re getting anxious about the person’s experience because it’s triggering something in you and you want to interrupt it, yeah, be aware of those things and wait and ask yourself, Why am I talking? But then sometimes there is a good reason for it. And then the question is, have you given ample timing and encouragement for it to keep unfolding on its own? So for instance, somebody might be feeling really stuck and blah, and sometimes, eventually we end. Up talking about that more and exploring it. Yeah, it’s similar to other therapy. But first we’re AP to say, I think this might be a good time to go back inside with that feeling and see what comes and those

Dr. Signi Goldman 20:14

are things you are saying on the medicine. Yes, on and if you do end up exploring it, you’re exploring it on the medicine. In this example you’re

Michael Mithoefer 20:22

referencing on the medicine. Yeah,

Dr. Signi Goldman 20:24

I’m just, I’m emphasizing that only because I think a lot of people think, Oh, you just sit there and then afterwards you talk about an integration and that’s a you do, but that’s a not the same thing that you’re referring to here. Yeah,

Michael Mithoefer 20:36

good point. Signi, yeah, it is true that the preparation and the integration sessions are, there’s more talking, and they’re more directive. Maybe, I mean, there’s a lot of the same spirit, but there the integration sessions. Yes, you do tend to talk about it more, but yes, we’re talking about the medicine sessions. And yes, you may end up exploring it in the medicine session, if you’ve given an ample you know something is necessary. I mean, often it’s just unfolding and nothing’s necessary, then stuck. Have you given ample time and encouragement for it to unstick on its own, which often happens if you invite somebody to go inside, or it might happen if you say, Where, what are you noticing in your body? With that, yes, yeah, you work a little bit with what’s happening in the body, and it will release. So we like to try other, less directive ways of inviting access to their own ability to get unstuck and can unfold the process without anything from outside. That’s that’s more accurate than anything we’re going to do. So that’s one, is it necessary to have you given ample time and encouragement to have it unfold on its own with a little suggestion. And then third, if both those conditions have been met and something is necessary, what’s the spirit in which you offer something? You offer it as a possibility or a choice or even an encouragement, but never a directive

Dr. Signi Goldman 22:21

like an invitation. Invitation, I can take it or not yes,

Michael Mithoefer 22:25

and we tell people in the preparation session, and we may say it again right then. We don’t want to push you into anything that isn’t where you’ve you know. You know better than we do about whether you’re ready to go there. But would you be willing to go inside and with that question always emphasizing the choice because it’s, it’s, there are a number of reasons for that. One is it’s not going to work very well otherwise. But the other is, we actually believe that they know better than we do on some level. There’s some levels on which we may have really good suggestions and we in a way, may do way we, you know, we have more experience than they do, so we may have reason to think that something would be helpful. But there are also many factors that their inner protectors know about that we don’t know about. Yeah, yeah. We want to honor those that inner protection and we don’t. You know, it may be, well be that there’s some block that would be helpful to remove at the right time, but there may be some reason why that’s not the right time that we don’t know about. So ultimately, we invite, we may have been encouraged, but we never push. So that’s the third element. Are you offering it in a way that they can either accept it or reject it easily,

Dr. Signi Goldman 23:55

right? And they feel comfortable either way, that they have permission to do that? Yeah? And have you know they so they’re encouraged to be tracking what’s trying to naturally unfold inside of them, and honor what feels ready to happen. And also, there’s some resistance to something honoring that, like the client is you’re not getting ahead of that, is what I hear you saying in if you have an intervention to offer you. You do offer it, but you offer it as a choice exactly gentle way. Yeah,

Michael Mithoefer 24:26

and we, we use that term. We sometimes say, Don’t get ahead of the medicine, you know. So in lay their track. Yes, they are tracking their experience. But there’s a trap there too, because we invite people, you know you don’t have to figure out what to do next and let go and trust that your inner healing intelligence will show you

Dr. Signi Goldman 24:48

yes and so often that that shows up in the form of emotion or body sensation or something they don’t even have a story for anyway, and you you want to be able to track that. Yeah, so I think to put this into language for the audience, and maybe you and I can toss this back and forth. Maybe your language is something I’m interested in. Is it correct to say that you are in dialog with the client enough to let them know that you’re present with them and that they have that support, but you’re not leading them or or kind of telling them what to do in any way. Yes, and then when something is coming up for them, you are first encouraging, you know, creating an encouraging environment for things that just spontaneously, like unfold the way they are spontaneously unfolding. But if you feel like you have an intervention, a therapeutic intervention, that would help with this, and your experience is that sometimes that’s the case, then you will offer that a big you’ll dialog with the client around offering that in an invitational way and giving them them. They may take you up on a domain, not but you encourage them to do to check in with their own inner healing intelligence around that as well. Like, would it feel? Does it feel? Would it feel right to do this or not? Some sort of, you know, that kind of an idea when you’re offering an intervention. Yeah, that fair. Okay. Is there anything I missed with that? Like, what else would you add to that?

Michael Mithoefer 26:21

Well, maybe, how about a few examples, maybe would help that clear. So the first one about checking in with people. I think a good example is you might have seen the video. You probably have a Marine veteran who was in his third uh MDMA session. He had two lower dose, 275 milligram which were very powerful. And then he was in his first 125 milligram session. And there was a period of time when he was lying back on the futon, kind of propped up, looking straight, kind of up at the ceiling talking about really, really painful things that had happened in Iraq and after Iraq and I went on for a long time. He was and if you somebody looked in the room, they would have might have thought he didn’t even know we were there, because yeah, and I were sitting on either side. He’s not talking to us. He’s just processing out loud. And after a long time, we began to wonder, you know, felt we should check in in some way. So Annie, I think Annie asked him, What are you noticing about the MDMA, and he said, It’s allowing me to talk about things, and Roman feel things in a way that I never had before. And and he said, Are you feeling connected to us? And he said, Yeah, yeah,

Dr. Signi Goldman 27:58

I love that example. That’s why

Michael Mithoefer 28:00

I’m able to talk about these things. If I feel connected to you, I would not be I don’t think I’d be able to talk about these things. Okay, that’s that part. I

Dr. Signi Goldman 28:10

just want to riff on that for a second, because I love that example, because it brings up two things that I think are often misunderstood. One is Annie is doing a check in there. I call that a tracking promp check in prom you know she’s saying she’s checking in with him. If you haven’t dialogued with him for a while, right? Like, I will just give a frame of reference that I teach a lot of people that work with ketamine, and those sessions are shorter. MDMA sessions are a lot longer. That is relevant for how much you’re checking in or how much silence you’re sitting in, in some kind of practical ways that I you know, we won’t get into today. But there are also for for the purposes of honoring the inner healing intelligence and the non directive approach, all the teachings are the same. And one thing that I often find myself really encouraging people to do is just those check ins periodically, because I have learned that when someone is on the medicine, they don’t find it disruptive to be checked in. They actually find it reassuring that the therapist or therapist team is tracking them, and even, like you said, they may not be overtly naming that they feel accompanied, but if they feel accompanied by you as a therapist, it makes a huge difference in this relational way. And there’s I also love that she sort of checked in on what some people think of as transference, but she checked in on how he was feeling about the relationship with you guys in the room. There’s often a lot there. You know, there’s a lot of their sense of being held untethered to you while they’re in the altered state is actually what creates a lot of the safety for them, sometimes to go to more challenging places. But it also can create a lot of the healing, the relational healing. See if, that’s if they have relational trauma. And so I one of the, I mean, I guess I’ll just use the word mistakes. But one of the mistakes that I see a lot of, like people out there in the cap world, the ketamine assisted psychotherapy world, is they’re dosing people, frankly, a little too high. They’re dosing them so high that they can’t really dialog. But regardless of that, they’re not checking in with them or giving them any kind of verbal or touch or any kind of cues to let them know that they’re still there. So the client just goes out in outer space, and they don’t have, they don’t know, have any way of knowing that the therapist is still present with them, unless the therapist is letting them know that, and so they feel like it more afraid, or they feel alone, or they feel like, you know they were just out there on their own. And I think that that creates, there’s a loss of a lot of like therapeutic potential there. When you just let the client go off on their own, there’s zero dialog, and you’re just sort of sitting in the room, and they don’t, they don’t know you’re still there. So So that’s me talking a lot, but something I keep seeing, and I I am often telling people, lower the dose enough so that they you you can dialog with them enough in a way that’s non directive, not interfering, and certainly don’t just talk at them the whole time. That goes without saying, but that they know you’re occasionally, that they know you’re present and that you’re tracking and that whatever’s happening, they’re present. You’re present for it is that’s a huge part of it. I’m gonna stop talking for a second, but

Michael Mithoefer 31:33

no, I’m glad you’re talking about that. Yeah, I agree. I mean, as Bessel van der Kolk says, healing happens in relationship, human beings heal in relationship. So yeah, it’s and, yeah, that really good point. You don’t have to be so afraid of interrupting their process. You know, another, another video I think you’ve seen is the, I think the person who talked the least in any of our, all of our MDMA sessions, it was another veteran who basically he only talked when we checked in with him every hour. He said things like, when I ask, when I ask myself, Should I talk about any of this? My body says, No, let’s just keep going deeper. Yeah, he would say things like that to us when we checked in, and it was a nice little connection. And then he’d go back in. We didn’t know anything about what had happened until he read it to us the next day. And there’s another example of why it seems like a really good thing that we didn’t get in the way with an agenda,

Dr. Signi Goldman 32:41

correct? That’s like, you knew when to let him be in silence. But he also, you checked in with him, and he communicated that, yeah, we ended it. It didn’t pull him out of it. He was able to stay with it. Yeah, and

Michael Mithoefer 32:54

there was important information we needed, because just like with the guy that we just talked about, you know, sometimes people often when people are inside and not talking, you know, some people talk to distract themselves, and when they’re inside, that’s great, that’s like gold. But it couldn’t be that they’re inside suffering in silence, isolating. And so, yes,

Dr. Signi Goldman 33:18

this is what I think keeps happening. And I hear these stories, people come to our our clinic, or even our training program, and we’ll say that that happened to them in other settings where they were, they were like desperately wanting, needing some sort of reassurance, or some sort of input that like things were going okay, or some sort of knowing they weren’t alone. Yeah, and they got they felt abandoned because the therapists didn’t say anything at all, or didn’t, and a lot of people also weren’t using touch. But that’s a different well, we’ll have a different podcast on that one, but regardless, there’s no you know. So I think that especially if you have relational trauma, or you have wounding patterns around relationship or abandonment, or any of that, then you can you can accidentally re traumatize someone by abandoning them in this session. Yes,

Michael Mithoefer 34:11

absolutely. And I guess I just realized I have another rule of threes that I do now this there are three things you need to know when you check in, because this guy that we talked about, who only talked every hour, somehow gave us all these three things without knowing he that’s what we needed. But what we needed to know was a is, are they having an important process? You know, because sometimes people might just be in there waiting for something to happen or, yeah, yeah. So like

Dr. Signi Goldman 34:46

thinking, I wonder what time it is. Are they going to ask me anything anytime

Michael Mithoefer 34:51

soon? And what he said at one point, I mean, we didn’t ask him that, but he said, there’s a lot, half a lot going on. So we knew there was a lot. Anthony. And the second thing we needed to know, and are they handling it? Okay, uh huh. And he you asked, he said, it’s, it’s, it’s beautiful. The music fits perfectly for so he was handling it well. And is there some is he Hanley, well, what’s the third thing? Well, I’ll think of the third maybe later. I had a third thing that I usually talk about in the training, about that. Well, it’s connected to us. That’s the third thing. Yeah, I was actually gonna say, that sounds funny, yeah. And he said, he said, Thank you for at one point, he just said, Thank you for being here with me, something like that. So we knew all those three things. So you do need to know that you don’t want her to be suffering in silence. You don’t want him to be not having an experience or bought and you don’t want them to be overwhelmed and not handling it without you knowing about it. Yes, know those three things. And you know the part about something going on also means it’s moving. Yes, it was clear that it was moving, so in that, in which case, then there is nothing more needed from us.

Dr. Signi Goldman 36:22

Yes, I think that’s beautiful. So I’m going to reiterate, I’m going to reiterate that in a minute for the audience, and one clarifying question for those that don’t know, how long is an MDMA session typically?

Michael Mithoefer 36:35

Well, our sessions are eight hours altogether, just kind of getting organized and talking and waiting for them, right? So the strong MDMA effect, I would say, is usually three to five hours.

Dr. Signi Goldman 36:48

So in a three to five hour session, it sounds like you had a policy of checking in once an hour if they were in silence, even though I know that wasn’t necessarily typical. Why? And I think it’s what you just said. But you know why? Just Is it because you needed to make sure one, that there was an important process happening to that they were handling it okay, and that they knew you were present. They felt the sort of relational presence of you there accompanying them on the journey. Yeah, okay. I think that’s lovely, like I we teach that same concept, which is to do a check in periodically if there’s a certain stretch of silence the the if the time frame is shorter, because these sessions are shorter. But I think that the concept is really similar. And you know, we, when we early on in this, we would interview people afterwards, you know, about their experience, especially trainees coming through and doing their own experiential sessions. We talk, we process a lot like in a teaching way. What was it like for you? And a lot of these conversations, always, the person will say that when they are checked in on, when they have been silent, and then they’re checked in on, they never feel it as interruptive. It doesn’t pull them out of the process. They feel it as supportive, yeah, and the reason is because we’re not checking in telling them to do something. We’re just checking in letting them know we’re present and and letting them know that they can share whatever’s happening or or they cannot. And if they do share it, we’re we’re happy to mirror it back and just be present for it with them. So it’s not, you know, and to the extent that we are dialoguing around the content, we’re either mirroring it back, just to kind of let them know that we’re hearing it and we’re tracking it, or we’re kind of what we call deepening prompts, which is really what else you noticing? You know, what else is present, maybe in the body or maybe in the mind, but never introducing any ideas out of our own agenda. So there’s a lot we’ve just said here. One is, I think I would like the audience to hear like, don’t sit in silence for an entire session and then talk about it afterwards. Check in periodically. I mean, it’s just a really great like, nuts and bolts piece there. And when you do check in your intention is these three things that that you Michael, have just named like, is there, is there something? Is there a process happening that’s therapeutic or valuable? If not, then that might, we could talk about what you would do if not, and then, if there is, you know, then they’re make sure they’re okay and that they don’t need any extra support. And then, thirdly, let them know in a relational way that you’re still present, and you’re still tracking them. You’re not on your phone, reading your email and zoned out, you’re fully present with them, and that that’s a huge part of what creates the healing container for them to stay in the process, right?

Michael Mithoefer 39:38

I think so, yeah. I mean, I know some people that say they can read and then be when somebody’s inside and be present. But for me, it’s a practice to not check email, not read, not do anything, but do my best to be present with that person. Sometimes my mind wanders, of course, and then I try to gently bring that so to me. Uh, there’s great power in the fact that you’re present in between the times you’re interacting. And so when they come out, you’re right there.

Dr. Signi Goldman 40:10

And I think one of the the humps that I a lot of very new practitioners need to get into, is is just the verbal being at verbal check in because they’re they’re intimidated, or they feel like they just want to sit and they miss that opportunity to stay in, to create that connection and to reassure the client of the connection. It’s just checking in. How are you doing? Okay, you know, then that’s it. Or what are you noticing? Which is what the that is, that example you gave with Annie, just doing that that quick, you know, checking in, letting you know I’m here, kind of idea, and that anything that’s happening is okay, and to want to share it. And if, if you share it, we can. And sometimes people do share it, and then you can work with it. And then this is another point you raised earlier. Then you can work with that, that whatever process they’re in, using therapy techniques that you have as long as you’ve been through a training enough to know what which ones are appropriate and how to do that appropriately, but you can actually do therapy while someone’s on the medicine,

Michael Mithoefer 41:12

absolutely, sometimes very helpful to give somebody some direction if they’re really stuck, if That’s if you’re using it in service of what’s trying to happen, rather than in service of your agenda that you think this person needs to have. You know, prolonged exposure therapy or internal family systems therapy or psychodynamic therapy, whatever, once something starts to happen. Maybe what you your training and experience in one of those things could be a very useful tool to help somebody kind of get unstuck in the process. On,

Dr. Signi Goldman 41:54

and I know I keep saying this, but on the medicine we’re talking about, while still on the medicine, I keep saying that, because, again, I think a lot of people, a lot of people go, Oh, that’s the stuff you do in integration. Yes, yes, and it’s it. I think it’s fascinating to me that I really think this comes from some lack of awareness or education on this, but also some intimidation people feel when they’re new. Sure about, you know, how and how much to step in, and that’s thing that you just sort of have to learn by doing. But we do, at least in our training program, we we do a lot of mentoring and prompt and modeling of that. We show them videos, and we do a lot of you know, because my my belief is that if you don’t do that, you’re really failing, like, I know we’ve said this quite a few times, but failing the to hold the relational safety of the of the experience

Michael Mithoefer 42:50

and something that’s not helpful, and then you can have a repair with the person,

Dr. Signi Goldman 42:58

yeah, I have a Teacher once who just is, this comes from hakomi. I think actually, it’s this really simple. Like, you know, you offer, you know, the sort of offered intervention, like, as an experiment. That’s a hakomi language for it. Like, we, you know, we could experiment with trying this or this, what do you think? And you’re, you’re saying this to the client, or you kind of offer a a prompt that doesn’t match. And then if it, if you can tell by their body language, that’s just not it. You then, you know, the teaching was just to say, okay, that’s not it. And then just keep, you know, like it doesn’t have to be a big deal, because, and it is true that when someone’s on an altered state, in my experience, they roll with that. It doesn’t, that doesn’t land, you know, it doesn’t interrupt them or derail them or anything like that. They always say afterwards that they really appreciate just the connection attempts, the dialoging

Michael Mithoefer 43:53

that well, it’s kind of, you know, as Dick Schwartz talks a lot about this, it’s great for the therapist to realize you don’t have to know the answer. You can find, you can try it and see, or you can ask, just ask, and if it’s not right to say, oh, sorry, that’s not it. You know, it’s you don’t have to, like, get out of this idea. I gotta have us all figured out for this person.

Dr. Signi Goldman 44:17

Yeah, I love that I was, it’s almost like a mutual collaboration between you and the patient or client’s inner healing intelligence with you just following along, but offering like, you know, is it this or this? Or is it or, you know, touch isn’t a good example of this. There’s often like, you know, check in, at least the way we do it, like check in with your check in with what’s happening, which is a way of saying, check in with your own inner healing intelligence, and check in and see if it would feel what it would feel like if I put my hand here, or whatever, and you, and you prompt them to actually go in and check and then they will know. They’ll say, Yes, actually, that you. Yeah, would be supportive. That would help or No, it’s not quite that, right? Yeah. So if you give the the client the permission to and the sort of acknowledgement that they have the ability to to check in with that and really authentically say what, what they’re what feels like it’s unfolding, and what feels right or supportive, then yeah, you’re really following along and and asking them, yeah, but you’re still using your skill sets, just not, you know, not in the same way you would in ordinary therapy. But like, one example of that that you already mentioned is you mentioned Dick Schwartz. So parts work shows up a lot. So you can use your therapist skills with working with parts, not the same way you would in ordinary awareness, maybe, but you, it helped you. You can die. You can go there when someone’s going through something really traumatic, you can move into like working with that if someone’s having some really somatic experience, you can do somatic interventions. And this is on the medicine. I know I keep saying that,

Michael Mithoefer 46:04

yeah, I mean, I’m trained in, I used to be certified in internal family systems therapy, and I find that extremely useful in this work. And sometimes it never comes up, but often, you know, we do have one little pilot that we haven’t published, showing that on active doses of MDMA, people start talking about parts a lot more often, like set, almost 80% of the time.

Dr. Signi Goldman 46:31

He actually did an interview with Dick shorts, and he mentioned that, he mentioned that you had told him about that he was, he was really intrigued by that with this, yeah, working with psychedelics, yeah,

Michael Mithoefer 46:43

um, so and, you know, but the majority of the time, thinking about it in terms of the IFS principles that I learned from Dick and others is very helpful for me to sort of track one way of thinking about what’s happening, which is what it is. But sometimes, if there’s stuck or something, I end up doing, what could, you know, rarely, but it does happen sometimes, in the medicine sessions, there’s a little section that could look like an internal family systems therapy session, if, if the person was, you know, really in that and it wasn’t shifting, and they needed some more interaction, then it could look like ifs most of the time it’s more like ifs informed, yeah, for me and sometimes, but sometimes the principles come in really handy. Because, you know, one thing that we’ve noticed watching many, many hours of videos. It’s been great because we got to train the MAPS therapists, and then we got to watch them work on the videos, and then give them consultation about it. And you know, what we saw was we had a really great bunch of therapists, and they, I mean, they did very well in general, but when they were when they weren’t adhering to the inner directed approach, so much would be either. When they, you know, would say, like, like, that person was kind of reaching out and asking you for for more direction. How come you didn’t respond? And they would say, Well, we were trusting the medicine and then our healer. And I’m like, great, but don’t trust it that much. You know, you’re there for a reason. Yeah,

Dr. Signi Goldman 48:27

you are there for a reason. Otherwise they could be unclear.

Michael Mithoefer 48:31

But the other side is they were all really good therapists and had a lot of good training, and if they started being what I would call directive in a way that wasn’t consistent with my idea of the inner directed approach. They would do something useful. You know, it would be helpful, but they don’t know what they would have been missing, like that guy that we only checked in with every hour, the experience he read us the next day they wrote down was he had this whole experience of his friend who died, who couldn’t save their spirit, get up and forgive him and hug him and help him forgive himself. It was a whole mystical, you know, trans, personal, deeply healing, mystical experience that went on over time that he didn’t even have time to tell us about at the time. So if we decided he needed to be doing imaginal exposure of some kind, right? Never have happened, right?

Dr. Signi Goldman 49:40

You would have just completely derailed him, right, or created a jarring kind of experience for him, right, right? That’s the balance, I think, and that, uh, and there’s an art to that, but it also can be taught. And I think step one is, do check in. We’ve covered that, but if you. Don’t check in, then you don’t even know to what degree you like, you don’t even have a map for what’s going on with the person at all. They’re just in some sort of silent experience that might not even they may not be fully Okay, or they may need a relational check in, and you just wouldn’t know. And when you do check in, give them permission to shrug it off if they’re in a place like, like, you’ve named like, you know, an example of that, from my experience, would be someone saying, when you check in with them, they say, Oh, I’m good, I’m I’m like, I’m talking to my grandfather. Then you would say, okay, like, you would just let them be in that, talking to your grandfather. He in that. Yeah, you know, you don’t need to analyze that in that moment. You don’t need to ask them questions about it, that they’re in it, right? But if you know, but a lot of times, when you check in with people, they have something going on that they want to either they want to hear reflected back, even if you don’t analyze it, they just want it to hear it reflected back, to know that it’s been witnessed in some way, or that there’s they’re being tracked, and then that’s, that’s sometimes that’s enough, and other times, people are actually in a process where some sort of therapeutic intervention is would be helpful or valuable, and then, and then you do that, and but you wouldn’t know if you don’t check in. Some people are very verbal, and verbalize the whole time, and they’ll just cue you right to everything, but not, but a lot of people don’t. And in the ketamine world, a lot of therapists are dosing too high, so the person is in the stratosphere. They don’t even, they’re not even aware of they’re like, they’re an ego dissolution state. They’re not gonna dialog about anything. That’s kind of a practical piece.

Michael Mithoefer 51:41

Yeah? Well, and there’s one, I think that’s a beautiful summary. Yeah, in one way, it’s not very complicated, check it. But there’s an intermediate So, yeah, see if something’s needed, if, if something seems to be needed, is there a possibility of like, I’d say, well, to keep it simple, if something seems to be needed and something’s a little stuck, encourage them to go back inside for a while. This is, this is oversimplified, of course, but encourage them to go. This wouldn’t be a bad way to just go. Encourage them to go back inside for a while, if maybe and see what they discover. That’s usually the invitation. Yes, often, then that’ll do it. If, either they sometimes they won’t stay inside for more than a couple seconds, and you try it repeatedly, it’s not happening, or they’re inside for quite a while and still the same place.

Dr. Signi Goldman 52:42

So to put some language to that for for listeners, I mean, at least, I think the way I often see that show up is you check in with someone and they may say, I’m stuck on this or this, or this is happening and I don’t like it, or, you know, they name something. And I think my version of what I’m hearing you say is is to mirror that back. Oh, you’re stuck in this, such as literally the same language, or this is noticing you don’t like it. Check in and see what else is. Let’s just take take a second to check in and see what else you can notice about that. You know, I’m right here with you. I’ll be here with you. I’ll check in. Let’s just go in and see what else is there. And then look, that’s sort of a way of prompting that, if I to put actual language on it, yeah, something like that. And then, you know, obviously you’re checking their body language, you’re you’re staying in touch to see if they’re really st, you know, they’re struggling. And then you can check in again and be like, where are you now? Or what are you noticing? Yeah, but those basic little things I just said there, there’s a lot of people not doing any of that because they’re not trained to do it. That is a real issue. But they’re they haven’t been encouraged to get comfortable doing it. Is the thing. I also see, no

Michael Mithoefer 53:59

and he doesn’t work now, if it’s still in the same place, I’d say, what are you noticing in your body when you’re experiencing that? And then get, would you be willing to just stay with that body thing? Or can your body, does your body want to move or express it in any way? Are there any sounds that want to come see if try to get not get too up in the head, and see if something will happen with the body. So I would say, in almost in vast majority of cases, you want to do those two things in that order, not working, check with the body, not working. Then that’s when you’re beginning to think about some of your therapy skills and exploring it, talking about it a little more.

Dr. Signi Goldman 54:50

Yeah, one of this, this brings up something which is a slightly different topic, but it is related in a way, which is that a lot of people coming in getting trained to do. Ketamine, this assist psychotherapy through our training program. And I, I believe all the others are coming from all different kinds of training backgrounds, and some of them don’t have somatic psychotherapy skills at all, so they’re not used to cueing the client to track their their somatic sensations. And they’re also not don’t have a lot of experience with working with that or you. So that’s one of the things we’re often encouraging people to do, is to get more, at least, to get an adequate amount of somatic ways of working with the body, so that they’re not completely at a loss when they need to, when they do need to move to working with the body. Even if you’re not a somatic therapist per se, you can adopt enough of those skills to be able to use that with people. And you kind of need to, because this is another piece. Is where you can accidentally abandon someone. Is when they’re what they’re re experiencing is very much happening in the body, and they don’t even really have a story for it, but it say a pre verbal it could be a pre verbal trauma. It could be a lot of things, but their body is processing it out and needs to be met, or, you know, that needs to be allowed to happen. And that’s another thing where I think that if you don’t meet that adequately, that can cause, you know, a sort of counter therapeutic experience.

Michael Mithoefer 56:19

I agree, yeah, yeah, that’s really important thing. Ian, you know, we got retrained in holographic breath work, which has a lot of body work. It’s actually kind of more dramatic than other things. Marcela and Bruce have trained in hakomi and somatic experiencing, and he’s trained in a Comey. So all those things are good ways of approaching. Or Pat ogden’s One psycho motor. Psycho

Dr. Signi Goldman 56:48

psycho motor, yeah, yeah. I use a lot of hakomi in my training program. Hakomi influence work because it I feel like it’s a really great fit because it’s the Comey model. Is so much about letting the client know when they’re in a, you know, even with eyes closed and in mindfulness that you are tracking them, yeah. And it also has this really, like, you know, appreciation for how content can show up in the body as well as, you know, the the thoughts or or emotion or story and so on. So, um, not everyone knows what hakomi is, but if you’re not a hakomi therapist, the take home is some sort of somatic skill set is important, and some comfort level with getting used to using it when you need to, because these, I guess this is a little bit of a soap box moment, and you’ll have to forgive me, but I feel there is a responsibility we have to these clients. It’s a huge responsibility because we’re putting them in a vulnerable, you know, position, being on these medicines with us, in a relational context. Yes, and if you do not make sure that you have these kinds of skills that Michael, you and I are talking about here you can, you can find yourself in a place where you kind of can accidentally do harm, even if it’s in subtle ways. Because this, you know, you can a person’s processing trauma or things are, you know, working through a process, and it needs to be met either somatically or what we were referencing earlier, needs to be met relationally. And if those things don’t happen, it actually just recapitulates the original wounding and and that the what I’ve seen this a lot, which is why I’m a little on the soap box. The client doesn’t necessarily have the words to describe that. They don’t even really rationally know that that’s what happened. So they’re not going to show up next day in integration and say, Hey, this you should have done this, because they don’t know that. But that’s when you have a people doing this work that maybe don’t have those skills. And I would kind of like to have this piece of education out there for that situation. You know, I know you come from a world where it’s you really have to have a lot of training and oversight to use MDMA, but that’s not the case with ketamine. So there’s a lot of people using ketamine in a lot of different ways right now, and one of the I’m because I have a training program and I have some visibility for Sandy and I one of our the roles that we find ourselves in is cautioning people against being too Cavalier and just assuming that they can just do what they’re doing. And it’s fine, yeah,

Michael Mithoefer 59:29

yeah. So important. Signi, you know, it’s um, these are not trivial experiences. And and I, you know, I think one of the problems is, you know, some people do fine just taking these medicines on their own. And so they get the idea that it’s pretty simple, yeah, and I think it’s, well, another rule of three is, maybe, here’s my opinion. Is because people are always saying, How come you’re not doing any studies where you just put somebody in a room with MDMA and leave them alone? And the reason is because we already know too much about MDMA and too much about PTSD to think that would be good idea. But I do think that you know, on a rough guess, probably the third of the people would have a profound healing experience on their own. It does happen, right? It happens

Dr. Signi Goldman 1:00:25

in recreational settings, accidentally, all the time.

Michael Mithoefer 1:00:29

Third of the people would probably have a pretty good experience and but it wouldn’t be very helpful for them. And then a third of the people would be in real danger, and some would commit suicide. Yeah, that’s the reality. These are not thank

Dr. Signi Goldman 1:00:43

you for saying that, because this is not something to be played around with. It’s not something to be taken lightly. And you know, I do supervision and mentoring Sandy and new as my my partner does, as my business partner does as well. And we often are doing mentoring, like career mentoring, or even like case supervision for new career ketamine therapists, either trained by us or trained in other places. And I’ve definitely had some conversations with people that are more like, you know that? Oh gosh, it’s tricky. I guess I’m often saying something like, yeah, what you’re doing might be fine the first 1020, maybe even 30 times, because a lot of people like you just said, Michael, a lot of people can kind of roll. And the and the the meta, the experience itself, will have healing content in it, and for the most part, they will feel like it was interesting, if not actually helpful, and you’ll feel like, great, I’ve got this. This is actually kind of easy, yeah, but then you’re going to get, you’re going to get client number 39, or 40, and you’re going to do what you’re doing, and you’re going to harm them, and you’re going to have this bad outcome, because what you’re doing is actually you’re just kind of winging it, and you’re relying on the fact that the medicine has its own innate healing ability to just assume that that’s always going to happen, and you’re not taking responsibility for the role of the therapist as an active, you know, part of the process and as a responsible part. And I, I, like you said, a lot of times these medicines are just, you can leave someone alone, and some of them would do great, and some wouldn’t. And if you don’t know that, and you can, you can see your first 20 people and be like, Oh, this is no big deal. And people get a little bit overconfident, no. And then they also do this thing where they coast on the coat tails of the inherent healing properties of the medicine without and just like, let that do all the work, and they just kind of don’t do anything. Or they, and this is a little more concerning, they coast on the the fact that the experience itself is impressive, like being on a psychedelic especially for a client who’s never done it before, is that intense experience, and they sort of basically coast on the fact that they gave someone an intense experience and that, as if that in itself is like the meaningful outcome, yeah. And then, you know what I mean. So anyway,

Michael Mithoefer 1:03:19

yeah. And I And then sometimes the therapist gets inflated by that too, and the patient can project it onto the therapist, thinking, What an incredible therapist that I’ve had such an intense experience. And a therapist can start thinking that also, and then you can get into boundary problems and all of that. So,

Dr. Signi Goldman 1:03:39

yeah, yeah. I just, actually, we just did an interview with Paul Richards the other day, and we had a conversation about what I’m about to say now. So this is, this is my second time saying this. It’s just so true. My this, this, doing this kind of work should not make you feel like you’re a great therapist. Doing this kind of work, in my experience, is humbling. It’s humbling because you are witnessing this thing that unfolds from the client’s inner healing intelligence. You’re witnessing that, and you are present for it, and you’re responsible for being present for it in all these ways you and I are discussing today, but you’re not making it happen like so usually you come out like, whoa, witness to that. That was amazing. I didn’t do that at all. It was a privilege to be there. And also, like, you are, I like this idea of midwife thing, it like the midwife doesn’t give birth to the baby, but she has an important role. You have to have the midwife there to be the person who’s done it many, many times, has experience. Can be reassuring, can step in with authority when needed. Can encourage and can just support the natural process. Us, yeah? And I think that’s our role, is we have to, but that that doesn’t mean we just, like the midwife doesn’t show up and just sit there and do absolutely nothing while the woman gives birth. You still have to show up and be you have a role, yeah?

Michael Mithoefer 1:05:12

And that’s a great analogy too, because without the midwife, a lot of births would go okay, too. But yes, ones that wouldn’t

Dr. Signi Goldman 1:05:20

that make I wanted? Yeah, and a lot of women would be a lot more scared, yeah. Well,

Michael Mithoefer 1:05:25

luckily, human beings have learned some skills to help each other not die in certain situations. And this is that’s that kind of thing, yeah,

Dr. Signi Goldman 1:05:34

yeah. Well, thank you for allowing that soap box moment. I guess I am in in ketamine world that there is, is a little more of the wild west right now. So I, I feel responsible for just putting out a note of caution around those kind of things. But really, we are mostly here today to sort of, you know, hearing, hear what we have just heard you say about the non directive approach, and the fact that it’s an non directive approach is still an active therapy intervention. It’s just the it’s one of following and relationality and not steering or leading. Yeah, fair. Okay, yeah. So it’d

Michael Mithoefer 1:06:14

be a lot simpler if you either just did nothing, or you either did manualized prolonged exposure therapy or something. But it turns out, it’s not that simple.

Dr. Signi Goldman 1:06:25

Yeah, well, I very much appreciate you having this conversation with me and jumping on on short notice. There’s a lot more that I would be happy to talk about, but I want to respect your time as well. So are there any closing thoughts or things that you think that we should make sure to put out there while we have this opportunity before we before we close today?

Michael Mithoefer 1:06:47

Well, my main closing thought is how important this is to have education and good training for therapists working with psychedelics. I think it’s so critical because, as you say, it can be deceptive, and it’s, it’s pretty bizarre. Now, MDMA has slowed down over the therapy questions from the FDA, but meanwhile, of course, ketamine is approved as an acidic years ago, so all these people are doing work with this powerful psychedelic with absolutely no regulation or

Dr. Signi Goldman 1:07:20

right? It’s so ironic, right? Even training.

Michael Mithoefer 1:07:23

So I’m so glad that you and others are stepping up to train people to use ketamine in a way that’s makes sense. So therapist training, and I think therapists self experience in a legal therapeutic context with these medicine is also very important, you know? Yeah, I think if I hadn’t had my own experience with MDMA and other psychedelics, like it would be much harder to trust the inner healing process or have a feeling for the depth of the experience people can be having in front of you if you haven’t had it yourself. So,

Dr. Signi Goldman 1:08:03

oh yeah, I agree so much. This is actually why we put the experiential part of our training first, yeah? Because when you give the experiential parts first, then when you go in and you teach ideas like the non directive approach, people intuitively get it more right. They’re almost confused. They go, Oh yeah, I get, I see why. You know, they naturally kind of catch on, because they’ve experienced being on the receiving end, yeah, and I agree it would be really so that’s an interesting connection, just to make. Is like to this Our topic today is the non directive approach, but it is much more understood by a trainee who has experienced the medicine themselves, and so maybe a sort of public servants service announcement that we can jointly get behind is for training programs to overtly talk about this non directive, directive kind of confusion that people have, and to teach how to teach the non directive approach as maybe a person centered approach, or whatever it was that Rick said, what was it the inner directed, inner directed so let’s teach it as inner directed approach, where, but you’re still, you still Are verbally dialoging with the client and you are,

Michael Mithoefer 1:09:24

what’s that in the medicine session? In

Dr. Signi Goldman 1:09:26

the medicine session? Yes, thank you. And how do you do that? Is part of the responsibility of what a training program needs to address so that this misunderstanding out there. Okay, I have loved this conversation. I thought, I think it is so timely and so valuable from a safety point of view. And also it’s just really interesting and fascinating, but and also it is powerful, because these are the tools that we use to to in this work that also are. To make the, you know, this is what makes this work so powerful and potent, is using these tools. Yeah, right. And this is what, you know, we are the collaborator with the client’s inner healing intelligence, yeah? And we need to know our role in that collaboration, which is that we’re not in charge of it, but we are showing up in service of it. And, and this is what it looks like, is these things that you’ve described. So I love how you’ve given, like, the these threes. So we have some actual, like, concrete bullet teachings here. And so I’m gonna, I’m gonna put that in the summary below, when we, when we post this, like, these are the three bullet points that Michael said for this and this and this and this, because I think my experience as trainees really, they really are craving some sort of nuts and bolts, what to do, what to do and and that’s super helpful for them. So, so thank you for doing this. I hope we get to talk more about other stuff in the future, like somatic that conversation would be really fun to have. But thank you for your time today.

Michael Mithoefer 1:11:02

Yeah, well, thanks, that was really fun. And to be continued,

Dr. Signi Goldman 1:11:06

yeah, To be continued. Take care. Michael, bye, 

Outro 1:11:12

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